Healthcare Provider Details

I. General information

NPI: 1528730744
Provider Name (Legal Business Name): IRENE WANCHING LIEM PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRENE LIEM PSYD

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 09/29/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 30TH AVE STE 203
KENOSHA WI
53144-1632
US

IV. Provider business mailing address

111 BARCLAY BLVD STE 368
LINCOLNSHIRE IL
60069-3673
US

V. Phone/Fax

Practice location:
  • Phone: 847-420-8825
  • Fax:
Mailing address:
  • Phone: 847-420-8825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5187-57
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: